Nutrition in surgery

1. NUTRITION IN SURGERY

2. NUTRITION IN SURGERY
 Aim of nutrition support is to identify patients at risk
for malnutrition and to meet their nutritional
requirements
 Malnutrition has high risk of complications plus
mortality

4. NUTRITIONAL REQUIREMENTS
 Calories provided mainly by carbohydrate and fat
 Fat = 9 kcal/g
 Carbohydrate = 4 kcal/g
 Protein = 4 kcal/g
 Daily caloric requirements: 30-35kcal/kg
 Metabolic stress associated with sepsis, trauma,
surgery or ventilation lead to increase energy
requirement (35-40kcal/kg/day)

5. MALNUTRITION
 Malnutrition:
 condition that develops when the body does not get
the right amount of the vitamins, minerals and other
nutrients it needs to maintain healthy tissues and
organ function
 Can occur in people who are either undernourished
or overnourished

6. COMPLICATIONS OF
MALNOURISHMENT

7. NUTRITIONAL ASSESSMENT
 History
 Physical examination
 Laboratory investigation
 Nutritional assessment score

8. HISTORY
 PRESENTING COMPLAINTS
Vomiting
Dysphagia
Diarrhea
 CO MORBIDITIES
Obesity
Malignancy
Inflammatory Bowel Disease
 SOCIAL & DIETARY HISTORY
Socio economic background
IntakeAmount

9. PHYSICAL EXAMINATION
 General appearance( emaciated, apathetic look)
 Assessment of body fat stores (Skin fold
examinationover biceps and triceps, subscapular
region)
 Assessment of protein stores (Muscle bellies of
biceps,triceps, supra and infraspinatus)
 Assessment of metabolic stress (indirect
calorimetry, temp, wbc count, pulse, positive blood
culture, abscess)
 Physiological fn - poor wound healing, early
fatiguability, grip strength, resp muscle fn test

10.  Anthropometric Measurements
Weight, height & BMI, IBW
Skin-fold thickness → biceps & triceps
IBW= (Ht-152.4) x 0.91 +50 (male)/45.5 (female)
Mid-arm circumference
 Signs of Malnutrition
Hair-easy pluckability
Face-nasolabial seborrhoea
angular fissures of lip
Muscle bulk-temporalis, thenar eminence, lumbricals
Skin- increased fold, hyperkeratosis, non healing ulcers
Limbs - dependant edema

11. LABORATORY
 FBC Hemoglobin (HCMC anemia), Total
Lymphocytes count
 LFT-Serum albumin
 Serum Transferrin
 Serum Prealbumin
 Others
Nitrogen balance
Electrolytes/BUSE/ creatinine

13. NUTRITION SUPPORT GIVEN IN CASE
OF
 Past medical history
 Involuntary loss
 Blood loss >500ml
 BMI < 18.5 kg/m2
 Serum albumin <3 or transferrin <200mg/dl
 Severe burns, trauma, sepsis, pancreatitisFailure to
thriveNPO > 7 days

14. STEPS IN NUTRITION SUPPORT
 Assessment of Nutrition
 Resuscitation
Fluid & electrolytes derangements
 Nutritional Requirements
Caloric goal- start with 10-15kcal/kg/d and
increased slowly up to 30 35kcal/kg/day
 Routes & Methods of Feeding
Oral, enteral, parenteral or combinations
 Monitoring
Adequacy, complications

15. INITIATING NUTRITION SUPPORT

16. ENTERAL NUTRITION
 Basics of enteral feeding
 Indication/Contraindication
 Enteral routesFeeding regime/ Types of formulas
 Complication

17. ENTERAL NUTRITION (EN)
 Delivery of nutrient into healthy and functioning GI
tract
 Most preferred and more physiologicalAdvantages
 Maintain gut mucosal integrity
 Maintain normal gut flora & pH
 Cheap & easily available
 Less complication

18. INDICATIONS AND
CONTRAINDICATIONS

20. FEEDING REGIME

21. COMPLICATIONS IN ENTERAL
NUTRITION

22. EARLY EN VS DELAYED EN
 Initiate nutritional support ( by the enteral route if
possible)
 without delay:
 Even in patients without obvious under nutrition, if
it is
 anticipated that the patient will be unable to eat for
more
 than 7 days
 In patients who cannot maintain oral intake above
60% of
 recommended intake for more than 10 days

23. PARENTERAL FEEDING
 BASIC OF PARENTERAL FEEDING
 INDICATIONS
 CONTRAINDICATIONS
 TYPES OF PARENTERAL NUTRITION
 CALORY REQUIREMENT
 COMPLICATIONS
 MONITORING PATIENT WITH PN

24. BASICS OF PARENTERAL FEEDING
 Delivery of all nutritional requirements by IV route
without
 the use of GIT (bypass GIT)
 Sterile liquid chemical formula
 May be delivered via :
- Central line
- Peripheral line

25. INDICATIONS

26. PRE OPERATIVE PN
 Indicated in :
 Severely undernourished patients who cannot be
adequately
 enterally fed
 Studies have shown that :
 Inadequate oral intake of >14 days = higher
mortality
 7-10 days of preoperative PN = improves
postoperative outcome
 in severe undernourished patient

27. POST OPERATIVE PN
 Indicated in:
 Undernourished patients = enteral nutrition is not
feasible / not tolerated
 Patients with postoperative complications
 impairing gastrointestinal function  unable to
receive and
 absorb adequate amounts of oral/enteral feeding
for at least 7 days
 Post operative PN is life saving in patients with
 prolonged gastrointestinal failure.

28. PN IS CONTRAINDICATED IN
 Functional and accessible GI tract
 Patient is taking orally
 Prognosis does not warrant aggressive nutrition
support (terminally ill patients)
 Risk exceeds benefit
 Patient expected to meet needs within 14 days

29. TYPES OF PARENTERAL NUTRITION

30. CALORIE REQUIREMENT

31. FORMULAS AVAILABLE AT HTAA
 2-in-1 mixtures : glucose + protein aggregate
(Nutriflex Peri, Nutriflex Plus)
 3-in-1 mixtures : glucose + lipids + proteins
(NuTRIflex Lipid Peri, NuTRIflex Lipid Plus, Kabiven
range)

32. MONITORING PATIENTS ON PN

33. COMPLICATIONS OF PN
Acute
Refeeding syndrome
Expansion of extracellular volume, fluid overload
Hyper/hypoglycemia
Fluid or electrolyte abnormalities
Catheter leak
Air embolism
Catheter related sepsis

34. COMPLICATIONS OF PN
 Late
Metabolic bone diseases : osteoporosis
Hepatic complications : fatty liver, liver failure,
hyperammonemia
Gallbladder complications: cholestatic jaundice
Venous thrombosis
Catheter related sepsis
Vitamin and traced element deficiency

35. REFEEDING SYNDROME
 Metabolic complication = in severely malnourished
patients
 Potentially fatal condition - may be successfully
managed
- prevented if detected early
 Pathophysiology
 Metabolism shifts : catabolic -> anabolic state
 Insulin is released - triggering cellular uptake of K+,
PO4, Mg
 Profound depletion those electrolyte extracelullarly
-hypo PO4, hypo Mg, hypo K+, hypo Ca multiorgan
dysfunction
 PN initially delivered = maximum of 10 kcal/kg/day
= raised gradually to full needs within a week

36. COMBINATIONS OF ENTERAL AND
PARENTERAL FEEDING
 >60% of energy needs cannot be met via the
enteral route, e.g. in high output enterocutaneous
fistulae
 partly obstructing benign or malignant
gastrointestinal lesions which do not allow enteral
feeding.

37. ENTERAL VS PARENTERAL NUTRITION
 Studies have shown that:
 There are no significant differences in mortality rate
 There are no significant differences regarding length of
hospital stay

38. THANK YOU...